General:

The HIPAA Privacy Rule (45 CFR Parts 160 and 164) provides the first comprehensive Federal protection for the privacy of health and mental health information. The Rule is intended to provide strong legal protections to ensure the privacy of individual health information, without interfering with patient access to treatment, health care operations, or quality of care.

The Privacy Rule applies to "covered entities" which generally includes health plans and health care providers who transmit health information in electronic form. Covered entities include almost all health and mental health care providers, whether they are outpatient, residential or inpatient providers, as well as other persons or organizations that bill or are paid for health care.

Basic Principles of the Privacy Rule:
1. The Privacy Rule protects all "protected health information" (PHI), including individually identifiable health or mental health information held or transmitted by a covered entity in any format, including electronic, paper, or oral statements.
2. A major purpose of the Privacy Rule is to define and limit the circumstances under which an individual's PHI may be used or disclosed by covered entities. Generally, a covered entity may not use or disclose PHI to others, except:
a. as the Privacy Rule permits or requires; or
b. as authorized by the person (or personal representative) who is the subject of the health information. A HIPAA-compliant Authorization must contain specific information required by the Privacy Rules.
3. A covered entity must provide individuals (or their personal representatives) with access to their own PHI (unless there are permitted grounds for denial), and must provide an accounting of the disclosures of their PHI to others, upon their request.
4. The Privacy Rule supersedes State law, but State laws which provide greater privacy protections or which give individuals greater access to their own PHI remain in effect.

Permitted Uses or Disclosures of PHI Without Authorization:
Extensive provisions of the Privacy Rule describe circumstances under which covered entities are permitted to use or disclose PHI, without the authorization of the individual who is the subject of the protected information. These purposes include, but are not limited to, the following:

1. A covered entity may disclose PHI to the individual who is the subject of the information.
2. A covered entity may use and disclose protected health information for its own "treatment, payment, and health care operations."
a. Treatment is the provision, coordination, or management of health care and related services for an individual, including consultation between providers and referral of an individual to another provider for health care.
b. Payment includes activities of a health care provider to obtain payment or to receive reimbursement for the provision of health care to an individual.
c. Health care operations include functions such as: (a) quality assessment and improvement; (b) competency assessment,, including performance evaluation, credentialing, and accreditation; (c) medical reviews, audits, or legal services; (d) specified insurance functions; and (e) business planning, management, and general administration.
3. Permission may be obtained from the individual who is the subject of the information or by circumstances that clearly indicate an individual with capacity has the opportunity to object to the disclosure but does not express an objection. Providers may also rely on an individual's informal permission to disclose health information to an individual's family, relatives, close personal friends, or to other persons identified by the individual, limited to information directly related to such person's involvement.
4. When an individual is incapacitated or in an emergency, providers sometimes may use or disclose PHI, without authorization, when it is in the best interests of the individual, as determined by health care provider in the exercise of clinical judgment. The PHI that may be disclosed under this provision includes the patient's name, location in a health care provider's facility, and limited and general information regarding the person's condition.
5. Providers may use and disclose PHI without a person's authorization when the use or disclosure of PHI is required by law, including State statute or court order.
6. Providers generally may disclose PHI to State and Federal public health authorities to prevent or control disease, injury, or disability, and to government authorities authorized to receive reports of child abuse and neglect.
7. Providers may disclose PHI to appropriate government authorities in limited circumstances regarding victims of abuse, neglect, or domestic violence.
8. Providers may disclose PHI to health oversight agencies, (e.g., the government agency which licenses the provider), for legally authorized health oversight activities, such as audits and investigations.
9. PHI may be disclosed in a judicial or administrative proceeding if the request is pursuant to a court order, subpoena, or other lawful process (note that "more stringent" NYS Mental Hygiene law requires a court order for disclosure of mental health information in these circumstances).
10. Providers may generally disclose PHI to law enforcement when:
a. Required by law, or pursuant to a court order, subpoena, or an "administrative request," such as a subpoena or summons (Note: the "more stringent" NYS Mental Hygiene Law section 33.13 requires a court order for disclosure of mental health information in these circumstances). The information sought must be relevant and limited to the inquiry.
b. To identify or locate a suspect, fugitive, material witness or missing person (Note: under Mental Hygiene Law section 33.13 this information is limited to "identifying data concerning hospitalization").
c. In response to a law enforcement request for information about a victim of a crime (Note: under Mental Hygiene Law section 33.13 this information is limited to "identifying data concerning hospitalization").
d. To alert law enforcement about criminal conduct on the premises of a HIPAA covered entity.
11. Providers may disclose PHI that they believe necessary to prevent or lessen a
a. serious and imminent physical threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).
12. An authorization is not required to use or disclose PHI to certain government
a. programs providing public benefits or for enrollment in government benefit
b. programs if the sharing of information is required or expressly authorized by statute or regulation, or other limited circumstances

"Minimum Necessary" Rule:
A covered entity must make reasonable efforts to use, request, or disclose to others only the minimum amount of PHI which is needed to accomplish the intended purpose of the use, request or disclosure. When the minimum necessary standard applies, a covered entity may not use, disclose, or request a person's entire medical record, unless it can specifically justify that the entire record is reasonably needed.
The minimum necessary standard does not apply under the following circumstances:
a. disclosure to a health care provider for treatment;
b. disclosure to an individual (or personal representative) who is the subject of the information;
c. use or disclosure made pursuant to an Authorization by the person (or personal representative);
d. use or disclosure that is required by law; or
e. disclosure to HHS for investigation, compliance review or enforcement.

I have read and understand this privacy policy.

Payment is due at time of service. Please note that you will be required to keep a credit card stored securely in the client portal. Your card will be charged at the beginning of each session. If you plan to use any out of network benefits with your insurance, I can provide a superbill for you to submit for possible reimbursement. It is solely your responsibility to verify your out of network coverage BEFORE our first meeting. I am not responsible for any issues that arise with your insurance. 

If you need to change or cancel your appointment time, the earlier notice you can provide me with, the better, so that I can offer your appointment slot to another client in need. I require at least 24 hours notice for an appointment cancellation.If you cancel within the 24 hour time frame there will be a $100 cancellation charge. If you miss a session without any notification you will be charged the full rate. 

If you are running late for an appointment, it is your responsibility to let me know. I will hold your appointment for you for 15 minutes. After this window, whether or not I can see you will be based on my discretion and you will still be charged for the full session.

Your card will be automatically charged for missed sessions/sessions not cancelled within the 24 hour time frame.

I have read and understood the payment, cancellation and lateness policies. 

Your company covers a certain amount of sessions per calendar year as noted in the Modern Health portal. They operate under a "use it or lose it" policy by the end date as listed, and then the sessions renew. Please note that if you change/cancel your appointment within 24 hours or no show for a scheduled session, it will come off the top of one of your sessions. For example: if you have 10 sessions to use and then you no show for a a scheduled session, you will then have 9 sessions remaining.

I have read and understood how the Modern Health sessions operate.